High-tech solutions not the answer to ER wait times, experts say

Alberta's ER wait time app can change from minutes to hours in blink of an eye

More and more people are checking websites and mobile apps before they go the emergency room to find out how long the wait will be, but experts warn that these tools are not always the best way for patients or hospitals to approach the seemingly intractable problem of long wait times. (iStock)

Checking a mobile app for the latest emergency room wait times before you rush out the door might seem convenient, but the high-tech tool may leave some patients feeling misled.

Alberta Health Services posts real-time wait times on its app for 15 hospitals in Edmonton and Calgary and hopes to expand the number of facilities it covers. The time posted on the app represents how long it should take to see a doctor in the emergency department.

The University of Alberta Hospital, where the family usually went, showed a wait time of two and a half hours. So, instead, Morrison took her mother to Grey Nuns Community Hospital, which had a posted wait of only 18 minutes.

"I thought this was good, because she's in a lot of pain, and we needed to see somebody right away," Morrison told the CBC's the fifth estate. "At the time, I was thinking, she'll get help right away, within that time is what I thought would happen."

Instead, her mother waited three hours to be seen, and, Morrison claims, bled to death internally from an aneurism while waiting several more hours to be admitted.

App 'not perfect'

The fifth estate investigated wait times as part of Rate My Hospital, a special report on Canada's hospitals. It compared ER wait times at three hospitals in Edmonton against the app and found that posted times could change from 15 minutes to hours in the blink of an eye.

The investigative show also learned that the average wait time between arrival and being admitted to a ward at Grey Nuns Community Hospital is 17 hours, more than twice the provincial target and one of the longest in the province.

A screen short of the Alberta Health Services wait times app for emergency departments in Edmonton.

Paul Parks, an ER doctor who led the campaign to improve wait times in Alberta, says wait time apps are a very blunt instrument and need to be considered in the context of all the other complex factors that come into play when assessing how fast people get treated in an ER.

"One of the troubles we have with this app is that seeing these numbers will probably set up expectations for the average person who may not understand the workings of the emergency department, that that's kind of a ball park guaranteed time they are going to get in, and when you read the fine print, that isn't the time at all," he said.

The detailed disclaimer on the Alberta wait times website says it provides general information and that wait times can change without warning and are not guaranteed.

Carol Manson McLeod, Alberta Health Services executive director of emergency for Edmonton, says patients should always go to the closest emergency room when they are sick, regardless of the posted wait time.

"Is it perfect? No, it's not perfect," she says of the app. "It's based on using some of our electronic systems behind the scenes [that] are predicting the wait times."

App puts onus on patient, not hospital

Alberta is planning to expand its use of the app, and other provinces, including British Columbia, Saskatchewan and Ontario, which already posts some ER wait times online, are looking at possibly emulating the experiment, but not everyone is a fan.

"I am in favour of timely reporting of ER performance and transparency," said Howard Ovens, director of the Schwartz-Reisman Emergency Centre at Mount Sinai Hospital in Toronto. "I'm not a fan of these apps."

Part of the problem, he says, is that the app estimates how long a patient will wait, but an individual's experience in the emergency room depends largely on how ill the person is.

"I don't want to discourage someone who is in need of care from coming because the estimated wait is long, or even delay them while they check the app," said Ovens.

The focus, he says, should be on how to reduce the wait times.

"These apps basically ask the public to smooth out their arrivals instead of asking the hospital to schedule staff to match patient arrivals," he said.

A low-tech solution

A small community hospital in southwestern Ontario has garnered attention for doing just that.

St. Thomas Elgin General Hospital cut the amount of time it takes a seriously ill patient to be admitted from 12 to seven hours and had the shortest wait times in the province last year.

Global laggard

Canada has the longest ER wait times among developed countries. A 2010 Commonwealth Fund study of 11 wealthy nations found that 31 per cent of ER patients in Canada wait four hours or more to be treated, compared to only four per cent in the U.K. and 13 per cent in the U.S.

The Canadian Institute for Health Information (CIHI) estimates that the median ER wait time in Canada is 2.5 hours, meaning 50 per cent of people wait longer than that, and that about one in 10 ER patients will wait more than eight hours. Wait times vary depending on a person's medical condition — heart attack cases, for example, spend more than twice the median time in an ER.

Alberta, which along with Ontario is the only province to report comprehensive wait times to CIHI, has the shortest ER waits in the country: 90 per cent of ER patients there are seen in 6.7 hours or less, compared to 7.6 hours in Ontario.

A 2011 British Medical Journal study of Ontario ER visits found that shaving an hour off the average length of stay in an ER could save 150 lives a year.

"You really have to look at the whole hospital flow," said Nancy Whitmore, the hospital's chief of staff. "We started to look at even just simple things in our emergency rooms, about how our rooms were set up — that they were set up in a way that everyone was the same."

The hospital began thinking about reducing wait times in 2008 after Ontario introduced a financial incentive program to entice hospitals to cut wait times to no more than eight hours for complex conditions and four hours for less complicated cases.

It looked at how the United Kingdom's National Health Service reduced its wait times and brought in KM&T Lean Evolutions, a consulting company from Britain that had helped hospitals there using so-called lean principles from the car manufacturing industry.

The first thing hospitals need to understand, said Scott Middleton, a former automotive engineer turned KM&T consultant, is "what are the people coming in for. How do they flow through the hospital ... [and] what is stopping the flow."

One of the first things he did was to get the hospital to start analyzing its metrics — everything from the time patients spent in the ER to the number of patients who were readmitted to hospital or who left the ER without being seen.

What the hospital found was that wait times weren't always related to how busy the emergency department was or the number of beds that were available.

"Sometimes, [wait times] were 13 hours, and we had actually more beds available for patients, and sometimes, we did better when our beds were really tight, so that didn't necessarily make sense," Whitmore said.

Early discharge plan key to efficiency

To tackle the problem, the ER split off patients with less serious problems who could be treated quickly into a rapid assessment zone. That also helped speed up how quickly seriously ill patients were seen.

Another key tactic was to start thinking about a patient's discharge plan right from the moment of admission.

The hospital asks admitting physicians to estimate a date of discharge so that everyone involved in the patient's care can aim to get that individual home by that date.

"That means that when they're medically well, we've already done all that leg work," says Whitmore, "versus getting them medically well for five or 10 days and then spending five more days organizing to get them home."

That approach has also enabled the hospital to free up acute care beds occupied by elderly patients who are awaiting transfer to long-term care homes or other facilities. It now works more closely with community care workers to enable as many of those patients as possible to return to their own homes.

All of these changes have earned the hospital $1.4 million in provincial pay-for-performance funding last year alone and have made the St. Thomas Elgin's emergency department a popular place.

The ER's patient volume has increased from about 35,000 to 45,000 in three years, and patients are coming from farther afield because they have heard about the short wait times. Thanks to the efficiencies the hospital has achieved, however, that increase has not put the kind of pressure on bed volumes that other hospitals experience.

However, the hospital is not resting on its laurels. It scored only a C on CBC's hospital report card, and Middleton vows to improve that in the 12 months he has left on his contract.

"We've still got a long way to go," he said. "We need to move our C ranking … up to an A."

To contact the Rate My Hospital team with tips or information related to the series, please emailratemyhospital@cbc.ca.